Nursing Assessment Chest Pain
History :
- What are the complaints? (specific words, location, severity)
- Are there other signs or symptoms? (lightheaded, dizzy, nausea, palpitations, indigestion, breathless)
- What was the resident doing when it started ?
- What is the contributing medical history? (Angina, CAD, MI, GI problem, respiratory illness, HTN, chest wall syndrome, anxiety) ?
- Are there other new status changes? (confusion, lethargy, agitation, slumping, flaccid limb, drooling)
- What cardiac meds are ordered? Any recent med changes? Is the resident on Coumadin and/or Aspirin ?
Physical :
- What are the vital signs? (apical pulse, any new rhythm change)
- If diabetic, what is the Accucheck reading ?
- What is the color & temperature of the skin? (dry, warm, cool, clammy, diaphoretic, pale)
- Are there new abnormal lung sounds? (wheezes, rales/crackles, rhonci)
- Is the abdomen tender on palpation? Bowel sounds? Last BM? DO NOT check for impaction !
- Any increase in edema (periorbital, hands, lower extremities) ?
Response :
- For known cardiac condition implement PRN Nitroglycerin order, Put to bed; apply oxygen at 2L via NC.
- If new onset chest pain put to bed, apply oxygen at 2L via NC and place emergency call.